J.-J. Eledjam

Training is required to improve the reliability of esophageal Doppler to measure cardiac output in critically ill patients

Objectives: Assessment of and effect of training on reliability of esophageal Doppler (ED) versus thermodilution (TD) for cardiac output (CO) measurement.Design: Prospective study.Setting: Intensive care unit of a university hospital.Patients: 64 consecutive critically ill patients requiring a pulmonary artery catheter, sedation, and mechanical ventilation.Interventions: Esophageal Doppler CO measurements were performed by the same operator, whereas TD CO measurements were carried out by other independent operators. A training period involving the first 12 patients made the operator self-confident. In the remaining patients, the reliability of ED was assessed (evaluation period), using correlation coefficients and the Bland and Altman diagram. Between training and evaluation periods, correlation coefficients, biases, and limits of agreement were compared.Measurements and results: During training and evaluation periods, 107 and 320 CO measurements were performed in 11 out of 12 patients and in 49 out of 52 patients, respectively. Continuous CO monitoring was achieved in 6 out of 11 patients and in 38 out of 49 patients during training and evaluation periods, respectively. Between the two periods, correlation coefficients increased from 0.53 to 0.89 (p < 0.001), bias decreased from 1.2 to 0.1 l.min−1 (p < 0.001), and limits of agreement decreased from 3.2 to 2.2 l.min−1 (p < 0.001).Conclusion: A period of training involving no more than 12 patients is probably required to ensure reliability of CO measurement by ED.

Endotracheal and aerosol administrations of ceftazidime in patients with nosocomial pneumonia: pharmacokinetics and absolute bioavailability.

Pharmacokinetic studies on ceftazidime, an aminothiazole cephalosporin with a wide spectrum of antibacterial activity, including activity against Pseudomonas aeruginosa, were performed in patients with nosocomial pneumonia. The concentration-time profiles of ceftazidime in plasma, urine, and bronchial secretions of 12 patients were investigated after intravenous (i.v.) (n = 12), endotracheal (n = 10), and aerosol (n = 5) administrations. In all cases a 1-g dose was administered. Concentrations of drug in all samples were assayed by high-performance liquid chromatography with UV detection. The elimination of the drug from the blood followed a biexponential (i.v. administration) or a monoexponential (endotracheal and aerosol administrations) decay, with an elimination half-life of 6 h and a total body clearance of 4.2 liters/h. The apparent volume of distribution was 0.36 liter/kg of body weight. Renal clearance of the drug accounted for 58% of the total clearance; 66% +/- 17.7%, 33.5% +/- 17.3%, and 6.59% +/- 3.45% of the administered dose were eliminated in urine as parent drug after i.v., endotracheal, and aerosol administrations, respectively. The absolute bioavailabilities were 0.47 and 0.08 for endotracheal and aerosol administrations, respectively. Very high concentrations were found in bronchial secretions after local administration. The MICs for 90% of the most important pathogens responsible for nosocomial infections were exceeded by concentrations in bronchial secretion for up to 12 h after i.v. infusion and for up to 24 h after endotracheal and aerosol administrations.

Analgésie postopératoire par cathéter fémoral après fracture du col du fémur chez la personne âgée : étude prospective randomisée ☆

INTRODUCTION The usefulness of peripheral femoral nerve block for pain management after hip fracture has been established. This prospective and randomised study compared the analgesia effect of a continuous femoral nerve block (CF) versus two conventional analgesia procedures after hip fracture. PATIENTS AND METHODS Patients. (n=62) scheduled for surgery under spinal anaesthesia were prospectively included. After surgery, analgesia (48 hours) was randomised: group FC (femoral catheter, anterior paravascular approach, initial bolus followed by continuous infusion of ropivacaine 0.2%), group P (iv 2 g propacetamol/6 hours), group M (sc morphine, 0.05 mg/kg per 4 hour). Intravenous morphine titration was performed, followed by subcutaneous (sc) morphine every 4 hours according to the VAS score. The primary end-point was the morphine requirements. Secondary end-points were VAS score, side effects, and mortality. RESULTS Demographic data and surgical procedures were similar between groups. After morphine titration, the VAS pain score did not differ between groups. All patients in-group M received additional morphine. Morphine mean consumption was increased in CF group: 26 mg (5-42) versus P: 8 mg (3-12) (p=0.0001) or M: 19 mg (8-33) (p<0.006) while constipation was decreased in P group vs CF. Percentage of patients requiring no morphine was similar between P (n=6; 28%) and CF (n=6; 28%) and greater than M (n=0; 0%). Hospital discharge, cardiovascular or pulmonary complications and mortality after 6 months showed no statistical difference. CONCLUSION Continuous femoral nerve block provided limited pain relief after hip fracture did not reduced side effects and induced an expensive cost.

Intravenous nicardipine for severe hypertension in pre-eclampsia--effects of an acute treatment on mother and foetus.

Objectives: To assess the efficacy in lowering blood pressure, and the safety for mother and foetus of an acute nicardipine therapy in severe pre-eclampsia.¶Design: Prospective clinical study.¶Setting: One university hospital obstetric unit.¶Patients: Twenty consecutive adult pre-eclamptic patients with severe hypertension.¶Intervention: Nicardipine, 1 μg/kg per min, was given intravenously to lower the mean arterial pressure (MAP) by at least 15 %. Then, the dosage was reduced by 1/3, and the final dosage was determined to maintain MAP at 20–30 % below the initial value, by increasing or decreasing the infusion rate by 0.5 mg/h.¶Measurements and results: Maternal MAP and heart rate (HR) were assessed every 5 min for 1 h. Foetal HR (FHR) was recorded throughout the study period and assessed for Fischer score. Gestational age, Apgar scores, birth weight, capillary filling time and the duration of stay in the paediatric intensive care unit (ICU) were used to evaluate the short-term perinatal outcome. A 15–30 % decrease in MAP occurred within 15–20 min in all patients. An increase in HR was noted, and two patients had severe tachycardia. Maternal side effects included flushing, headache, nausea and dizziness. FHR showed a transient decrease in acceleration episodes and occurrence of decelerations. No nicardipine-related foetal distress occurred. Four infants born during the study period did well at birth and had a good outcome.¶Conclusions: Acute nicardipine therapy can induce severe maternal tachycardia. No severe foetal or neonatal adverse effects occurred. This dose scheme requires comparison with alternative therapeutic options.

Article originalAnalgésie postopératoire par cathéter fémoral après fracture du col du fémur chez la personne âgée : étude prospective randomiséeAnalgesia after hip fracture repair in elderly patients: the effect of a continuous femoral nerve block: a prospective and randomised study☆

INTRODUCTION The usefulness of peripheral femoral nerve block for pain management after hip fracture has been established. This prospective and randomised study compared the analgesia effect of a continuous femoral nerve block (CF) versus two conventional analgesia procedures after hip fracture. PATIENTS AND METHODS Patients. (n=62) scheduled for surgery under spinal anaesthesia were prospectively included. After surgery, analgesia (48 hours) was randomised: group FC (femoral catheter, anterior paravascular approach, initial bolus followed by continuous infusion of ropivacaine 0.2%), group P (iv 2 g propacetamol/6 hours), group M (sc morphine, 0.05 mg/kg per 4 hour). Intravenous morphine titration was performed, followed by subcutaneous (sc) morphine every 4 hours according to the VAS score. The primary end-point was the morphine requirements. Secondary end-points were VAS score, side effects, and mortality. RESULTS Demographic data and surgical procedures were similar between groups. After morphine titration, the VAS pain score did not differ between groups. All patients in-group M received additional morphine. Morphine mean consumption was increased in CF group: 26 mg (5-42) versus P: 8 mg (3-12) (p=0.0001) or M: 19 mg (8-33) (p<0.006) while constipation was decreased in P group vs CF. Percentage of patients requiring no morphine was similar between P (n=6; 28%) and CF (n=6; 28%) and greater than M (n=0; 0%). Hospital discharge, cardiovascular or pulmonary complications and mortality after 6 months showed no statistical difference. CONCLUSION Continuous femoral nerve block provided limited pain relief after hip fracture did not reduced side effects and induced an expensive cost.

Multiple-dose pharmacokinetics of amikacin and ceftazidime in critically ill patients with septic multiple-organ failure during intermittent hemofiltration.

The pharmacokinetic parameters of amikacin and ceftazidime were assessed in four patients undergoing hemofiltration for septic shock. The parameters were assessed during hemofiltration and in the interim period. The concentration-time profiles of these two drugs in plasma, urine, and ultrafiltrate were investigated after intravenous perfusion (30 min). In all cases a 1-g dose of ceftazidime was administered; for amikacin, the dosage regimen was adjusted according to the patients amikacin levels (250 to 750 mg). Concentrations of drug in all samples were assayed by high-performance liquid chromatography with UV detection for ceftazidime and by enzyme multiplied immunoassay for amikacin. The elimination half-life (t1/2) and the total clearance of amikacin ranged from 31.1 to 138.2 h and from 5.4 to 8.9 ml/min, respectively, during the interhemofiltration period in anuric patients. Hemofiltration substantially decreased the t1/2 (3.5 +/- 0.49 h) and increased the total clearance (89.5 +/- 11.8 ml/min). The hemofiltration clearance of amikacin represented 71% of the total clearance, and the hemofiltration process removed, on average, 60% of the dose. During hemofiltration, the elimination t1/2 of ceftazidime (2.8 +/- 0.69 h) was greatly reduced and the total clearance increased (74.2 +/- 11.2 ml/min) compared with those in the interhemofiltration period (9 to 43.7 h and 7.4 to 16.8 ml/min, respectively). About 55% of the administered dose was recovered in the filtrate, and the hemofiltration clearance of ceftazidime was 46 +/- 14.3 ml/min. A redistribution phenomenon (rebound) in the amikacin and ceftazidime concentrations in plasma (35 and 28%, respectively) was reported after hemofiltration in two patients. The MICs for 90% of the most important pathogens were exceeded by the concentrations of the two drugs in plasma during the whole treatment of these patients.

Sédation et analgésie en structure d’urgence. Réactualisation 2010 de la Conférence d’experts de la Sfar de 1999

Sedation and analgesia in emergency structure. Reactualization 2010 of the Conference of Experts of Sfar of 1999 B. Vivien *, F. Adnet , V. Bounes , G. Chéron , X. Combes , J.-S. David , J.-F. Diependaele , J.-J. Eledjam , B. Eon , J.-P. Fontaine , M. Freysz , P. Michelet , G. Orliaguet , A. Puidupin , A. Ricard-Hibon , B. Riou , E. Wiel , J.-E. de La Coussaye o,4,** a Samu de Paris, département d’anesthésie-réanimation, hôpital Necker–Enfants-Malades, université Paris Descartes–Paris-5, 149, rue de Sèvres, 75730 Paris cedex 15, France b EA 3409, Samu 93, hôpital Avicenne, université Paris-13, 125, rue de Stalingrad, 93009 Bobigny, France c Samu 31, pôle de médecine d’urgences, hôpitaux universitaires, université de Toulouse, 1, avenue Jean-Poulhès, place du Dr.Baylac, 31059 Toulouse cedex 9, France d Département des urgences pédiatriques, hôpital Necker–Enfants-Malades, université Paris Descartes–Paris-5, 149, rue de Sèvres, 75730 Paris cedex 15, France e Département d’anesthésie-réanimation-urgences, centre hospitalier Lyon-Sud, hospices civils de Lyon, 69493 Pierre-Bénite, France f Smur pédiatrique régional de Lille, centre hospitalier régional universitaire de Lille, université Lille-2, Nord-de-France, 5, avenue Oscar-Lambret, 59037 Lille cedex, France g Structure des urgences, hôpital Lapeyronie, université 1, 191, avenue du Doyen-Gaston-Giraud, 34295 Montpellier cedex 5, France h Pôle réanimation urgence, service d’aide médicale urgente hyperbarie (RUSH), réanimation des urgences, CHU de SainteMarguerite, 270, boulevard Sainte-Marguerite, 13009 Marseille, France i Service d’accueil des urgences, hôpital Saint-Louis, université Paris-7, 1, avenue Claude-Vellefaux, 75010 Paris, France j Samu 21, département d’anesthésie-réanimation, centre hospitalier universitaire de Dijon, faculté de médecine, 3, rue du Faubourg-Raines, BP 1519, 21033 Dijon cedex, France Annales Françaises d’Anesthésie et de Réanimation 31 (2012) 391–404

Is epidural anaesthesia using bupivacaine safe in patients with atrio‐ventricular conduction defects?

Bupivacaine is known to interact with the conductive system of the heart, also when used in epidural anaesthesia. Ten patients, undergoing bupivacaine epidural anasthesia for lower limb or pelvic surgery, who presented a history of cardiac conduction disturbances, were studied. The ECG was continuously monitored and a right ventricular bipolar electrode was used to monitor the following parameters: heart rate, QRS duration, QT, Atria‐His and His‐Ventricle intervals. No significant change was noticed, even in patients with a high grade conduction defect. The mean plasma level of bupivacaine was 0.33 ± 0.23 μg/ml. Based on this experience, it seems that lumbar epidural anaesthesia with bupivacaine can be safely used in patients with asymptomatic AV conduction abnormalities.

Analgésie postopératoire par voie locorégionale chez l'adulte: techniques perimédullaires et périphériques. Indications, effets indésirables et surveillance

Regional analgesia is a very effective way to treat postoperative pain. Lumbar and thoracic epidural analgesia are well adapted to major abdominal and thoracic surgery. Nevertheless, respiratory side effects induced by opioids are potentially severe and an adequate monitoring is essential. In orthopaedic surgery, perineural blocks are the best technique to manage postoperative pain and perineural catheters may be used. The importance of intra-articular analgesia, simple and safe, is not fully understood. The association of a local anaesthetic inducing a minor motor block and a strong sensitive block (bupivacaine, ropivacaine), with an opioid seems to be the best pharmacologic choice regarding quality of analgesia and safety. Benefits of postoperative regional analgesia on mortality and morbidity are not demonstrated. Medical and nursing staff and specialized units should improve quality of postoperative regional analgesia as well. General guidelines for the practice of regional anaesthesia must be closely followed.

Mécanismes de la toxicité cardiaque de la bupivacaïne

Of all the amide local anaesthetics, bupivacaine is said to be the most cardiotoxic. This toxicity is seen mostly when there is a sudden increase in the plasma concentration of bupivacaine. It involves both, or either, electrical and mechanical structures within the heart. The main site of action on cardiac conduction tissue is the Vmax of phase 0 of the action potential of fast-reacting structures (INa current). Bupivacaine, like lidocaine and the other class I antiarrhythmic drugs, blocks the sodium channels, this block being more slowly reversible. The disturbance of sodium channels throughout the heart leads to a decreased conduction speed throughout the conduction system, thus explaining possible acute conduction disturbances originating below the bundle of His. The ventricular dysrhythmias described are due to a re-entry circuit secondary to a slowing in conduction speed. However, the sinus bradycardias and junctional disturbances seen in toxic accidents are probably due to an inhibition of the slow current of the atrial and atrio-ventricular nodes (Isi current). The experimental observation of an increase in the atrial monophase potential and the corrected Ot interval suggests that repolarization currents are also involved (IK current ?). It would therefore seem that modifications in membrane permeabilities are the cause of the seriousness of the clinical picture. Bupivacaine, at toxic levels, has a direct effect on contractility. The negative inotropic effects seem to be due to a fall in the intracytoplasmic calcium concentration on which depends the excitation-contraction couple, as well as disturbed cellular energetic events dependent on the contraction. The fall in intracytoplasmic concentration is due either to a fall in the in-going calcium flux during membrane depolarization or to a change in the calcium release from the sarcoplasmic reticulum. The disturbance of cellular energetic events seems due to an uncoupling effect of local anaesthetics on phosphorylating oxidative reactions, which decreases the mitochondrial ATP synthesis essential for the contraction.Abstract Of all the amide local anaesthetics, bupivacaine is said to be the most cardiotoxic. This toxicity is seen mostly when there is a sudden increase in the plasma concentration of bupivacaine. It involves both, or either, electrical and mechanical structures within the heart. The main site of action on cardiac conduction tissue is the Vmax of phase 0 of the action potential of fast-reacting structures (INa current). Bupivacaine, like lidocaine and the other class I antiarrhythmic drugs, blocks the sodium channels, this block being more slowly reversible. The disturbance of sodium channels throughout the heart leads to a decreased conduction speed throughout the conduction system, thus explaining possible acute conduction disturbances originating below the bundle of His. The ventricular dysrhythmias described are due to a re-entry circuit secondary to a slowing in conduction speed. However, the sinus bradycardias and junctional disturbances seen in toxic accidents are probably due to an inhibition of the slow current of the atrial and atrio-ventricular nodes (Isi current). The experimental observation of an increase in the atrial monophase potential and the corrected Ot interval suggests that repolarization currents are also involved (IK current ?). It would therefore seem that modifications in membrane permeabilities are the cause of the seriousness of the clinical picture. Bupivacaine, at toxic levels, has a direct effect on contractility. The negative inotropic effects seem to be due to a fall in the intracytoplasmic calcium concentration on which depends the excitation-contraction couple, as well as disturbed cellular energetic events dependent on the contraction. The fall in intracytoplasmic concentration is due either to a fall in the in-going calcium flux during membrane depolarization or to a change in the calcium release from the sarcoplasmic reticulum. The disturbance of cellular energetic events seems due to an uncoupling effect of local anaesthetics on phosphorylating oxidative reactions, which decreases the mitochondrial ATP synthesis essential for the contraction.